HOW TO DISSECT A CODING ABSTRACT

1. HOW TO DISSECT A CODING ABSTRACT AKA – How the heck do I do this??? Lynn Thornton, RHIA, CCS

2. EACH CASE IS DIFFERENT… • And yet coding process is essentially the same. • Coding is like being a detective! • Your clinical knowledge and organization of data is important to your success. Lynn Thornton, RHIA, CCS

3. SO MANY DOCUMENTS, SO LITTLE TIME! • Know which documents you may code from. • Who has the final decision in a complex case regarding the final diagnosis. • What documentation you may use in coding the encounter. Lynn Thornton, RHIA, CCS

4. HAVING A PLAN OF ATTACK IS THE KEY! • What should you look at first? • Think, why was the patient here??? Lynn Thornton, RHIA, CCS

5. A Review of a Case Scenarios The patient was admitted for takedown of colostomy. The patient underwent a colostomy 3 months ago after colon resection was performed for perforated diverticulitis. The patient was taken to the OR for colostomy reversal with end to end anastomosis. Final diagnosis Perforated diverticulitis Procedure Colostomy Takedown Lynn Thornton, RHIA, CCS

6. FOLLOW THE YELLOW BRICK ROAD! Admission for colostomy takedown ABSTRACT cc H/P INFO What will you code? Hx Perforated Diverticula Status Post Colosomy Residual Diverticula Lynn Thornton, RHIA, CCS

7. CODE WHAT IS CLINICALLY RELEVANT! • PDX – Admission for Colostomy Takedown • Secondary DX: • -Diverticula, large intestine • Principal Procedure – Takedown Colostomy Lynn Thornton, RHIA, CCS

8. Coding is much like telling a story! • My review of codes should tell me this about the patient: • Principal reason the patient was admitted. • What other conditions are being monitored, medicated, assessed, and/or treated. • What services and procedures were performed. Lynn Thornton, RHIA, CCS

9. So, why don’t I code perforated diverticulitis??? • The patient was admitted for takedown of colostomy. The patient underwent a colostomy 3 months ago after colon resection was performed for perforated diverticulitis. The patient was taken to the OR for colostomy reversal with end to end anastomosis. Final diagnosis Perforated diverticulitis Procedure Colostomy Takedown Historical Condition Current Condition Lynn Thornton, RHIA, CCS

10. AND THAT, IS THE PROBLEM WITH PHYSICIAN DOCUMENTATION! Ok, so what the heck was the PDX anyway??? Lynn Thornton, RHIA, CCS

11. Case Scenario • The patient was admitted with abdominal pain in the RUQ. Workup included an EGD that showed some mild erosive gastritis and abdominal ultrasound was positive for gallstones. • PDX – Abdominal pain due to gastritis versus cholelithiasis. Procedure EGD with biopsy of the esophagus. • Think! • What is the CC? • What was found on workup? • What is the documented PDX? • What procedures were performed? Lynn Thornton, RHIA, CCS

12. Dissecting the abstract! The patient was admitted with abdominal pain in the RUQ. Chief Complaint Workup included an EGD that showed some mild erosive gastritis and abdominal ultrasound was positive for gallstones. Clinically Relevant! PDX – Abdominal pain due to gastritis versus cholilithiasis. PDX What are the guidelines for comparative and contrasting diagnoses? Procedure EGD with biopsy of the esophagus. Lynn Thornton, RHIA, CCS

13. POA • The problem for coders; • Did they have it when they walked in the door??? Gee, maybe I should document it was POA? Lynn Thornton, RHIA, CCS

14. HOW TO KNOW??? • Look for medications to treat on admission. • Look at lab values on day of admission. • Keep notes as you code based on the document type. • CC – from ER record or from H/P • POA DX – Review H/P • Scan for all conditions present at the time the order for admission was written. Lynn Thornton, RHIA, CCS

15. What about the EGD??? • Esophagogastroduodenoscopy - EGD • Service mandates scope is inserted to duodenum • Biopsy was up in esophagus??? Lynn Thornton, RHIA, CCS

16. IN ICD-9-CM • EGD with Biopsy – only one code for both the EGD and the biopsy regardless of location. Lynn Thornton, RHIA, CCS